Stock, composition and distribution of the nursing workforce in Brazil: a snapshot

Abstract Objective: to analyze the availability (in terms of stock and composition) and accessibility (in terms of geographical distribution) of the nursing workforce in Brazil. Method: this is a descriptive, cross-sectional study with retrospective data collection, identified by combining databases available on institutional websites and structured according to indicators from the World Health Organization’s “National Health Workforce Accounts”. The study considered nursing professionals at senior level (nurses) and middle level (nursing auxiliaries and technicians). Indicators of stock, composition, distribution (by age group and gender) and the ratio of nurses to doctors were included. Results: there was an increase in the number of personnel between 2005 and 2010, mainly in middle and technical level professionals. There are more personnel aged between 36 and 55, with a predominance of women in all categories, despite the increase in men. There was an uneven distribution of personnel across the country’s regions, with the Southeast having the largest number of professionals. The ratio of nurses to doctors is less than one in the South and Southeast. Conclusion: despite the large number of nurses, their distribution is uneven. The growth of nursing technicians has significantly outstripped that of nurses, indicating more intensive technical training policies than those found in higher education.


Introduction
The health workforce (HWF) is a fundamental component of health systems and services.The development of capable, motivated, and supported health workers is essential to the delivery of health care and to overcoming the obstacles that stand in the way of achieving national and global health goals.However, global HWF estimates show a shortage of 15 million workers in 2020, with a projected reduction to 10 million by 2030 (1) .
In addition to the shortage, many countries face major challenges in their HWF, such as the inadequate mix of skills and inequities in geographical distribution (2) .
Analyzing the current situation of HWF through reliable data and comprehensive research is essential for better understanding the forces driving worker shortages, skill mixes and geographical imbalances, as well as for planning and developing effective policies to address these issues (2) .Thus, the use of evidence for planning the HWF is of paramount importance for building and consolidating resilient health systems and services.This relevance has been recognized and evidenced in the face of the challenges faced worldwide in an international emergency scenario such as the COVID-19 pandemic (3) .
In this sense, political will and international cooperation are essential for the development and implementation of targeted national plans aligned with the use of knowledge in building and strengthening health systems.Especially in a context in which policymakers and managers are challenged to ensure the availability and accessibility of healthcare for the entire population, considering the increased demand for healthcare professionals in a context of shortages and poor distribution of these professionals (4) .
The literature emphasizes the contribution of the nursing and midwifery workforce to improvements in health, using a people-centered model of care, favoring proximity to users of health services and the community.
Nursing and midwifery, in particular, accounted for more than 50% of the shortage of health workers worldwide (5)(6) .
The creation of the Brazilian National Health System (Sistema Único de Saúde, SUS), which established the universal right of access to health care, has led to the expansion of public policies, both in terms of access and population coverage.Despite the expansion of nursing professionals' workplaces, especially within the SUS and Primary Health Care, attracting and retaining this workforce is a huge challenge for health managers (7)(8) .
In this context, Brazilian nursing, which comprised approximately 70% of the country's HWF in 2019, totaling more than 2.7 million professionals qualified to practice the profession, and representing a density of 12.97 professionals per thousand inhabitants in 2022, has an important role in the health system, far beyond its numerical representation (4)(5)(6)(7)(8)(9) .
Considering that the difficulty in implementing policies or strategies, as well as the lack of political support for monitoring programs and policies, are considered significant limitations that reflect on the decision-making process in the Brazilian context, this study aimed to analyze the availability (in terms of stock and composition) and accessibility (in terms of geographical distribution) of the nursing workforce in Brazil.

Method Study type
This is a descriptive, cross-sectional study with retrospective data collection, which followed the STROBE guide.

Study population
Information was collected on the nursing workers who make up the nursing team, i.e. nursing professionals (nurses) and mid-level associate (nursing auxiliaries and

Theoretical model and indicators for analyzing human resources for health
To guide the field of study, the conceptual framework based on the sequence of four critical dimensions: Availability, Accessibility, Acceptability and Quality (AAAQ) (10) was used, which presents the dimensions of availability, accessibility, quality and acceptability applied to HWF.The concept of availability is presented as the sufficient supply and stock of appropriate health professionals, with the relevant skills, production and combination of skills that correspond to the health needs of the population.
Oliveira APC, Mion ABZ, Galante ML, Di Donato G, Ventura CAA Accessibility is understood as: the equitable distribution of health professionals in terms of travel and transport time (spatial); opening hours and the presence of the corresponding workforce (temporal); infrastructure attributes (physical, for example, buildings adapted for the disabled); referral mechanisms (organizational) and the direct and indirect cost resources of the services, both formal and informal (financial) (10) .
To structure data collection, the National Health Workforce Accounts (NHWA) tool, developed by the World Health Organization (WHO) in its Portuguese version (2020) (11) was used.The analysis presented in this article focused on the availability of professionalsin terms of their number (density in relation to the national population) and composition (gender, age, level of training and ratio between nurses and doctors); and spatial accessibility (distribution by region), broken down by category, according to Figure 1.

Data collection and analysis
The data was identified through a combination of databases available on institutional websites: a) the Interagency Health Information Network (RIPSA) (13) platform, a network made up of governmental and non-governmental institutions (14) (15) , developed by the World Health Organization (WHO), which is based on the conceptual framework of the health labor market (11) : data on gender, age of nursing professionals for the years 2014, 2017, 2019, which may vary between those qualified to practice and those in practice; and d) The Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE) (16) , the country's main provider of data and information, meeting the needs of various segments of civil society and government bodies (17) : data on the Brazilian population, by federative unit and by region, was obtained from the IBGE's population estimates published in the Federal Official Gazette.
Although most of the proposed indicators only consider active professionals, the level of activity of the professionals used in the analysis varied according to the information available in the databases.Information available in published reports was also collected, such as: a) Integrated Management Report of the Federal Nursing Council 2019 (18) : presents the number and gender of professionals -nurses and nursing auxiliaries and technicians -by state for 2019; b) Business Intelligence

Accessibility Stock of active health workforce
Professional density at subnational -regional level.
Numerator: Number of active health professionals in subnational administrative units, defined in number of people.Denominator: Total population at sub-national level.

Availability Complementary
Ratio of nurses professionals to doctors -at national and regional level and by category.
Numerator: Total number of nurses/nurses licensed to practice.Denominator: Total number of doctors licensed to practice † .
*The AAAQ framework is a sequence of four critical dimensions to analyze: Availability; Accessibility; Acceptability and Quality; † According to the Organization for Economic Cooperation and Development (OECD) (12) , professionals licensed to practice are those who have training and qualification requirements and a license (registration/qualification) to practice.The concept of active professionals refers to those who have training and qualification as prerequisites for providing services to patients and communities, management, or teaching.Practicing professionals are those who provide direct services to patients and communities Rev. Latino-Am.Enfermagem 2024;32:e4287.
Commission Report Product 2 (19) : displays data on nursing professionals registered with the Regional Nursing Councils (Coren) in the states by professional category, gender and age group in 2010; c) Business Intelligence Commission Report (20) : with data on nursing professionals registered with the Corens in the states by professional category, gender and age group in 2011, and d) Profile of Nursing in Brazil (Final Report) (21) , resulting from the research project whose central objective was to outline the profile of the nursing team in Brazil.The document identified nursing professionals by age group in 2013.
Data was collected from December 2022 to April 2023 by two researchers simultaneously.Although the authors followed the same data search method for each database mentioned above, there was a lack of information, which made it impossible to collect all the years sequentially in all the databases used.
The data found was organized in the Excel application and the indicators described in Figure 1

Workforce availability
The total number of professional nursing registrations in the Federal Nursing Council (Conselho Federal de Enfermagem, Cofen) and Regional Nursing Council (Conselho Regional de Enfermagem, Coren) system was 2,767,741 in December 2022 (9) .When analyzing its composition, it was possible to identify that it is  2.
As for the characterization of professionals, when analyzing the distribution of nursing personnel (without distinguishing between categories) by gender, it can be seen that, despite a slight increase in the number of male professionals, women continued to predominate in the last two decades, from 1990 to 2019, representing 88.00% in 2019, as shown in Figure 3, sub-item (a).
A more detailed analysis of the professional categories from 1990 to 2011 reveals a slightly more pronounced increase in the male contingent among higher education professionals, from 6.42% in 1990 to 11.86% in 2011, as shown in Figure 3, sub-item (b).
From 2010 to 2019, when we analyzed the age distribution of nursing personnel, we found that, despite the data coming from different sources, there was a predominance of individuals between 36 and 55 years old.
However, in 2017 and 2019, there was a decrease in the percentage of nursing personnel under 35.The data showed that personnel under the age of 35 accounted for more than 35% in all the years studied, ranging from 35.70% to 45.90%, while those aged 56 or over accounted for more than 6% of all nursing personnel, with percentages ranging from 6.09% to 9.81%.This information was obtained from the number of records of nursing personnel by category for the years 2010 and 2011 (9) , for 2013 (21) and, for 2014, 2017 and 2019, extracted from the NHWA (15) .
To analyze the skills combination, we used the density and ratio of nursing and medical professionals in the country, Tables 1 and 2. When we compared the density of nurses to that of doctors per 10,000 inhabitants for the year 2022, it was slightly higher for nurses (  (9) and Interagency Health Information Network (RIPSA) (13) .
Population data obtained from the Brazilian Institute of Geography and Statistics (IBGE) (16) Figure 2 -Evolution of the number and density of nursing personnel per thousand inhabitants.Brazil, 1990-2022 Source: Number of professional nursing records, 2011: Federal Nursing Council, Cofen (20) ; 1990 to 2010: Interagency Health Information Network (RIPSA) (13) ; 2014 to 2019: National Health Workforce Accounts (NHWA) (15) ; Number of nursing professional registrations by category and gender: Federal Nursing Council (Cofen) (19)(20) and Interagency Health Information Network (RIPSA) (13) Figure 3 -Characterization of the nursing workforce by gender, total and by category.Brazil, 1990-2019  (9) ; number of inhabitants (Brazilian population) in 2022: Brazilian Institute of Geography and Statistics (IBGE) (16) and number of registrations of medical professionals: Medical Demography in Brazil 2023 (22) *The number of medical professional records was used to enable comparison with the nursing data;

Workforce accessibility
When analyzing the distribution of nursing personnel among the country's regions, it can be seen that the largest number is concentrated in the Southeast, followed by the Northeast, with the same distribution in the different professional categories.The North is the region with the lowest number of nurses in the country, but when analyzing the number of nursing professionals, nursing auxiliaries and nursing technicians, the region with the lowest representation is the Midwest, as shown in Table 2.
Although the Southeast is the most representative region in the country in terms of the number of nursing personnel in its different categories, it showed the lowest growth during the period from 2000 to 2022, considering the total number of nursing professionals and nurses.
The North was the region with the greatest growth in relation to the different categories analyzed, except for nursing auxiliaries.However, when looking only at nursing auxiliaries, the South and Midwest regions showed a decrease in the category, as shown in Table 2. Source: Numbers of registered nursing professionals by category for the year 2022, obtained from the Federal Nursing Council (Cofen) (9) and for the year 2000, obtained from the Interagency Health Information Network (RIPSA) (13) *ENF = Nurses; † Téc Enf = Nursing technicians; ‡ Aux Enf = Nursing auxiliaries;

Discussion
The density of nursing in the country, of approximately 130 nursing professionals and 32 nurses per 10,000 inhabitants in 2022, has been identified as higher than the mean for countries in the Latin American and Caribbean Region (LAC) and the Organization for Economic Cooperation and Development (OECD), which have just over 35 and 103 nursing professionals per 10,000 inhabitants respectively for the same year Oliveira APC, Mion ABZ, Galante ML, Di Donato G, Ventura CAA (information available for LAC for 33 countries, and OECD for 38 countries) (23) , demonstrating an apparent "excess of professionals" in Brazil.It is important to note that the global data may be considering practicing and/or active professionals, while the data analyzed for Brazil refers to professionals licensed to practice, considering the number of registrations with the Cofen/Coren System.
In addition, in Brazil, in 2022, seven out of ten nursing personnel will have a secondary and/or technical degree (75%), which is the opposite of the global scenario, in which 69% of professionals have a higher education degree (considering data from previous years).In the European region, nurses make up 70% of the nursing workforce (for example, the United Kingdom, with 80% of professionals with higher education) (24) .With the exception of a few countries, such as Canada and the United States (75.46% and 85.74% of professionals with higher education, respectively) (15,24) , the nursing workforce in the Americas is mostly made up of mid-level and/or technical professionals, although at a lower rate than in Brazil (59%) (25) .
During the period analyzed (1990 to 2022), two Enfermagem, PROFAE) (26) .The second period of growth in the density of nursing professionals, of around 22% between 2019 and 2022, partially contradicts the results of an international integrative review that examined 43 studies (pre-and post-COVID-19) and indicated a significant increase in the rate of intention to leave the profession after the COVID-19 pandemic, as also observed by the International Council of Nurses (ICN).
In addition, a survey of National Nursing Associations showed an increase in the number of nurses leaving the profession.In this context, factors related to this intention and/or abandonment are emphasized: heavy workload, insufficient resources, physical exhaustion and stress (27)(28) .Therefore, it is imperative to examine this scenario in the country, analyzing not only the number of professionals involved in direct care for patients and the community, but also the number of individuals who have chosen to leave this noble profession.
Despite being a young profession, with more than a third of professionals at the start of their careers and less than 9% close to retirement (2019), there is an aging of the profession in the country (2010 to 2019).A younger nursing workforce can help ensure the sustainability of the nursing profession.As older nurses retire, it is important to have a new generation to replace them and continue providing high-quality care (29) .Although this is far from the scenario in some countries in the Americas with substantially older populations, such as Panama and the Dominican Republic (with more than 26% of professionals aged 55 or over) (15) , and countries in Europe, such as Bulgaria, Iceland and the Republic of Moldova (with approximately 40% of professionals aged 55 or over) (30) , this information suggests the need to monitor this indicator and carry out analyses between the different categories, in order to better understand the flows in and out and the needs of professionals.
In relation to the characteristics of the nursing workforce, there is a predominantly female profile.In this study, it was possible to identify an increase in the male contingent, representing 12% of professionals qualified to practice in 2019, a slightly higher increase in the category of nurses (from 6% to 12% 1990-2011).Data on nursing professionals in practice indicate a percentage of 13.7% in 2021 for the country (16) .These figures are close to those identified in other countries in the Americas region, with 13% in 2019 (16) , with Argentina standing out with approximately 20% of male nursing professionals in 2020 (15,25) .
Although female health workers are responsible for providing the majority of care at all levels and in all settings, as they represent around 67% of salaried workers in the health sector, they encounter barriers at work.These barriers are not faced by male professionals, such as prejudice, discrimination, sexual harassment and violence, in addition to the disproportionate risks that have arisen during the COVID-19 pandemic (31) .
The integration of gender and age into HWF strategies is necessary to ensure that sensitive, evidence-based approaches are adopted for planning and managing professionals.The lack of accurate data on gender and age composition in several countries hinders the improvement of working conditions and career structures to support women's participation and progress in HWF, as well as valuing the contributions of women and their professionals in healthcare systems (32) .
By estimating the combination of HWF skills by comparing the ratio of professionals, information is obtained on the possibility of efficiency gains and also the ratio of nurses to doctors as a potential indicator of the quality of user care (2,33) .Brazil had a national ratio of 1.16 nurses in 2022 and two of its regions, the South and Southeast, had nurse to doctor ratios below 1 (0.95 and 0.99 respectively).These were identified as lower than Finally, there is a pressing need for new research and policies that thoroughly examine the effectiveness of integrating professionals into their roles and workplaces.This is crucial to understanding the growing demand for nursing professionals, a need that seems to intensify every year, despite the increase in the number of these professionals.

Conclusion
Despite the large number of nursing personnel, there is a disparity in their distribution throughout the country.
It is also possible to note that nurses, in addition to being in smaller numbers, have grown much less than nursing technicians in some regions of the country, so that the growth of nursing technicians has outstripped that of nurses, indicating more intensive technical training policies than in higher education.
nursing technicians).According to the 2008 International Standard Classification of Occupations (ISCO-08): professional nurse (ISCO code 2221) and associate nursing professional (ISCO code 3221) are equivalent to the Brazilian Classification of Occupations (Classificação Brasileira de Ocupações, CBO): nurses and equivalents (CBO code 2235) and nursing technicians and auxiliaries (CBO code 3222), according to the Professional Practice Law (Law No. 7,498 of June 25, 1986), which provides for the professional practice of nursing in the country.In relation to medical professionals, ISCO-08 code 2211 and 2212 and CBO code 2002 were used.

Figure 1 -
Figure 1 -National Health Workforce Accounts indicators and complementary indicators selected for information collection and analysis moments of significant increase in the number of nursing personnel in Brazil were identified.The first occurred between 2005 and 2010, when there was a significant increase in the density of personnel, almost doubling from 3.82 to 7.58.Nursing technicians played a key role in this increase, rising from 0.94 to 3.24.This expansion was driven by national strategies, such as the Nursing Workers Professionalization Project (Projeto de Profissionalização dos Trabalhadores da Área da Oliveira APC, Mion ABZ, Galante ML, Di Donato G, Ventura CAA picture of the situation.The results highlight changes over time, revealing a notable increase in the number of nursing professionals, especially at middle and technical level, between 2005 and 2010.In addition, the unequal distribution of professionals in different regions of the country was identified, with the Southeast region standing out in terms of quantity.The analysis also pointed to persistent challenges, such as the predominance of females in all categories and the need for more robust public policies to diversify and redistribute professionals across Brazil.These findings not only inform future decisions in the areas of health and education, but also offer valuable insights for formulating strategies aimed at improving the quality of health care and promoting equity in access to health care services across the country.In this sense, the importance of public policies that take statistics into account when planning and implementing policies and strategies is emphasized, in order to reconfigure the distribution of professionals to promote a more equitable allocation in all regions of the Brazilian territory.Of particular note is the effort made with the Program for Valuing Primary Care Professionals (Programa de Valorização dos Profissionais da Atenção Básica, PROVAB), which aimed to provide Primary Care and Family Health Strategy teams with nurses, dentists and doctors in remote and more vulnerable areas.

Element of the conceptual four AAAQ* Indicator area Indicator name Description used
Numerator: Number of health professionals, defined in number of people.Denominator:Total population.
2.33 to 2.80 in this period.Another moment to observe is the period from 2019 to 2022, which is during the pandemic, when the growth in the density of nursing personnel over three years is almost 22% (from 10.64 to 12.97), whereas in the previous period, the growth was approximately 14% (from 9.35 to 10.64), as illustrated in Figure this increase is constant and has been observed over the years, it is most significant between 2005 and 2010, when the density of personnel in the country practically doubled in five years, going from 3.82 to 7.58, respectively.Part of the reason for this increase were mid-level professionals, with nursing technicians rising from 0.94 to 3.24 and auxiliaries, from 31.83and 27.38 respectively), reaching a national ratio of 1.16 nurses professionals per doctor in the same year.
respectively).When analyzing the ratio of nursing professionals to doctors, a national ratio of 4.74 was identified, ranging from 3.83 nursing professionals per doctor in the South to 8.52 in the North.When analyzing the availability of this group of professionals in the country, as shown in Table1, there Oliveira APC, Mion ABZ, Galante ML, Di Donato G, Ventura CAA Source: Number of registrations of nursing personnel by category: Federal Nursing Council (Cofen)

Table 1 -
Density of nursing personnel, total and by category, per 10,000 inhabitants and ratio of nursing professionals, total and nurses, per doctor.Brazil, 2022 Source: Number of registrations of nursing professionals by category: Federal Nursing Council (Cofen)

Table 2 -
Number of nursing personnel, total and by category, and growth rate by region.Brazil, 2000 and 2022

Table 1 .
§ Prof Enf = Nursing professionals even though it has the fourth lowest number of nurses of all the regions.Although the Northeast region stands out in terms of the number of nursing personnel, ranking second in all categories, it has the second lowest density of nursing professionals and the lowest density of technicians and assistants combined.The great growth of the